A structured, evidence-informed walkthrough of a pregnant patient presenting with pelvic girdle pain — from initial history-taking through to safe osteopathic management.
Section 01
A thorough subjective history is the foundation of safe clinical reasoning in pregnancy. Below is the presenting case.
Name: Sarah (pseudonym)
Age: 31 years
Occupation: Primary school teacher
Gestation: 26 weeks (2nd trimester)
Gravida / Para: G2 P1 (one previous uncomplicated vaginal delivery)
GP Referral: Yes — cleared for manual therapy
Obstetric care: Midwife-led, no known complications
Bilateral posterior pelvic pain, worse on the right, radiating into the right buttock and posterior thigh. Onset at approximately 20 weeks gestation, gradually worsening.
Section 02
Pelvic pain in pregnancy has a broad differential. Systematic reasoning helps distinguish musculoskeletal causes from those requiring urgent referral.
| Condition | Key Features | Distinguishing Factors | Priority |
|---|---|---|---|
| Pelvic Girdle Pain (PGP) | Posterior pelvic pain, SIJ tenderness, worse with loading | Positive ASLR, P4 test; no neurological deficit | Primary Dx |
| Symphysis Pubis Dysfunction (SPD) | Anterior pelvic pain, pubic symphysis tenderness | Pain on adduction, waddling gait; often co-exists with PGP | Co-diagnosis |
| Lumbar Disc Herniation / Sciatica | Radiating leg pain, dermatomal pattern, possible neuro signs | Pain below knee, positive SLR, neurological deficit | Rule out |
| Piriformis Syndrome | Deep buttock pain, sciatic-like radiation | Positive FAIR test, pain on hip IR; no SIJ tenderness | Rule out |
| Urinary Tract Infection (UTI) | Dysuria, frequency, suprapubic pain | Urinalysis positive; systemic symptoms if pyelonephritis | Screen & refer |
| Deep Vein Thrombosis (DVT) | Unilateral leg swelling, calf pain, warmth | Pregnancy is a major risk factor; Wells score; urgent referral | Urgent referral |
| Preterm Labour | Regular uterine contractions, pelvic pressure | <37 weeks; cervical changes; obstetric emergency | Emergency |
| Placenta Praevia / Abruption | Vaginal bleeding, abdominal pain, uterine rigidity | Painless bleeding (praevia) vs painful (abruption) | Emergency |
| Sacral Stress Fracture | Severe localised sacral pain, unable to weight-bear | Rare; associated with osteoporosis of pregnancy; MRI confirms | Urgent imaging |
| Inflammatory Arthropathy (e.g. AS) | Morning stiffness >1hr, improves with activity | Pre-existing diagnosis; elevated inflammatory markers | Consider if atypical |
In pregnancy, always consider obstetric causes first. Only proceed with musculoskeletal assessment once red flags have been screened and excluded. Collaborate with the patient's midwife or obstetrician when in doubt.
Section 03
Examination in pregnancy requires modification for patient comfort and safety. Avoid prolonged supine positioning after 20 weeks.
Positive bilaterally (R > L). Patient reports difficulty lifting leg without pelvic instability. Improves with manual compression of iliac crests.
Positive on right — reproduces familiar posterior pelvic pain. Performed in supine (brief). High sensitivity for SIJ-related PGP.
Positive right — pain in posterior pelvis (not groin). Suggests SIJ involvement rather than hip pathology.
Negative bilaterally. No reproduction of leg pain below knee. Reduces likelihood of lumbar disc herniation with nerve root compression.
Sensation, power, and reflexes intact in both lower limbs. No saddle anaesthesia. No bowel/bladder dysfunction reported.
Positive right — pelvis drops on left during right single-leg stance. Indicates right gluteus medius weakness contributing to pelvic instability.
Section 04
Pelvic Girdle Pain (PGP) — Bilateral SIJ Dysfunction
Consistent with European Guidelines for PGP (Vleeming et al., 2008). Characterised by pain between the posterior iliac crest and gluteal fold, with or without radiation to the posterior thigh, arising in relation to pregnancy.
Symphysis Pubis Dysfunction (SPD) — pubic symphysis tenderness with functional limitation. Often co-presents with PGP and is part of the same pelvic girdle complex.
Relaxin and progesterone increase ligamentous laxity throughout the pelvic ring, reducing force closure of the SIJ.
Growing uterus shifts centre of gravity anteriorly, increasing compressive and shear forces on the SIJ and pubic symphysis.
Inhibition of deep stabilisers (transversus abdominis, pelvic floor, multifidus) reduces form and force closure of the pelvis.
Prolonged standing, asymmetric loading (carrying toddler), and stair climbing perpetuate the pain cycle.
Pain between posterior iliac crest and gluteal fold ✓
Positive P4 test and ASLR ✓
Lumbar spine not primary source; neuro intact ✓
Section 05
Treatment is tailored to the trimester, patient comfort, and clinical findings. Techniques are modified to avoid contraindicated positions and excessive force.
Reduce pain, improve function, and support the patient through pregnancy — not to achieve a structural "correction".
Work alongside midwife, GP, and physiotherapist. Communicate findings and any concerns promptly.
Use the least force necessary. Indirect and functional techniques are preferred over high-velocity thrust (HVLA) in pregnancy.
Rationale: Hypertonic right piriformis and gluteus medius contribute to altered pelvic mechanics and pain. Releasing these muscles improves force closure and reduces referred pain into the posterior thigh.
Position: Left lateral recumbent (side-lying). Pillow between knees for comfort.
Technique: Inhibitory pressure and longitudinal kneading to right piriformis, gluteus medius, and thoracolumbar erector spinae. 3–5 minutes per region.
Precaution: Avoid direct pressure over the SIJ in acute inflammation. Monitor patient comfort throughout.
Rationale: MET uses gentle isometric contractions to restore SIJ mobility and reduce muscle guarding. Safe and effective in pregnancy when performed in side-lying.
Position: Side-lying (left side down). Hip and knee flexed to ~90°.
Technique: Patient gently resists hip extension (posterior innominate dysfunction) for 5 seconds at 20% effort. Repeat 3–5 times. Reassess ASLR post-treatment.
Evidence: Supported by Vleeming et al. (2008) and Pennick & Liddle (2013) Cochrane review on interventions for PGP in pregnancy.
Rationale: The sacrum is central to pelvic mechanics. Indirect technique (moving toward ease) is gentle, non-provocative, and well-tolerated in pregnancy.
Position: Left lateral recumbent. Practitioner contacts sacrum with one hand.
Technique: Gently guide the sacrum into its position of ease (away from restriction). Hold for 60–90 seconds until a release is felt. Avoid any direct thrust.
Note: HVLA to the sacrum or lumbar spine is generally avoided in pregnancy due to risk of increased ligamentous laxity and patient discomfort.
Rationale: The thoracolumbar junction (T12–L2) is a common area of restriction that can reflexly affect pelvic floor tone and SIJ mechanics via the thoracolumbar fascia.
Position: Seated or side-lying.
Technique: Gentle articulation and soft tissue work to T12–L2 region. Diaphragm doming technique in seated position to improve respiratory mechanics and reduce intra-abdominal pressure.
Rationale: The pelvic floor, diaphragm, transversus abdominis, and multifidus form an integrated pressure management system. Dysfunction in any component affects pelvic stability.
Technique: Guided diaphragmatic breathing with gentle pelvic floor co-activation. Patient is taught to coordinate breath with movement (e.g., exhale on effort when lifting).
Referral: Consider referral to a women's health physiotherapist for formal pelvic floor assessment and rehabilitation.
Section 06
Effective management of PGP in pregnancy extends beyond the treatment table. A biopsychosocial approach with patient education is essential.
Numeric Rating Scale (0–10) at rest and on activity. Target: ≤3/10 on activity.
Active Straight Leg Raise (0–5 scale). Validated for PGP. Target: improvement of ≥1 point.
Patient-Specific Functional Scale — patient rates 3 key activities. Tracks meaningful functional goals.
PGP often resolves within 3 months postpartum, but ~20% of women have persistent symptoms at 1 year (Wu et al., 2004). Plan a postpartum review at 6–8 weeks. Reassess pelvic floor function, SIJ mobility, and return to activity. Breastfeeding maintains relaxin levels — ligamentous laxity may persist. Gradual return to exercise guided by symptoms.
Summary